Australian Diabetes Screening Study: impaired glucose tolerance and non-insulin-dependent diabetes mellitus

Stress hyperglycemia: A prospective study examining the relationship between glucose, cortisol and diabetes in myocardial infarction

AIM

We aimed to explore the relationship between stress, hyperglycemia and diabetes in myocardial infarction (MI), using serum cortisol as a surrogate marker for the severity of stress.

METHODS

Subjects with acute MI were prospectively recruited upon hospital admission. Serum glucose and cortisol were measured in addition to standard testing. Subjects were defined as having stress hyperglycemia (SH) if they had an admission glucose ≥7.8 mmol/L without a history of glucose intolerance. Subjects were followed up with glucose tolerance testing post-discharge.

RESULTS

Of the 200 subjects in the study, 58 had known diabetes/impaired glucose tolerance (IGT), and 45 had SH. There was a positive association between admission glucose and cortisol for the entire cohort (r_s = 0.26, p < 0.01). This relationship was present in the subgroup who had SH and then normal glucose post-discharge (r_s = 0.53, p = 0.03), but not in SH subjects who had diabetes/IGT on post-discharge testing. It was also evident amongst all subjects with normal glucose (r_s = 0.46, p < 0.01), but not those with diabetes/IGT in general. On multivariate analysis, admission glucose was a positive predictor and cortisol a negative predictor of abnormal glucose tolerance.

CONCLUSIONS

Our data suggests that SH with MI reflects either underlying glucose intolerance or more severe stress in people without glucose intolerance.

An Effective Model for Prevention and Management of Type 2 Diabetes

We developed and tested a cost-effective model for health promotion capacity building among community health volunteers (CHVs) within culturally and linguistically diverse (CALD) communities. Twenty multilingual CHVs, from CALD communities in Melbourne, underwent 3 days of education and training to deliver face-to-face education programs in their own language. Participants were instructed how to collect anthropometric data, make qualitative observations, and conduct diabetes knowledge questionnaires, before conducting mini education sessions with three members of their own community. Knowledge about diabetes among CHVs increased. CHVs were able to collect anthropomorphic data and knowledge surveys from community participants with greater participation than from outreach programs. Evidence-based data collected by CHVs could be incorporated into health education and promotion programs run by CHVs. Here we confirm that CHVs represent an effective tool for health promotion within CALD communities and have the capacity to incorporate evidence-based collection as part of their health education.

Random plasma glucose in serendipitous screening for glucose intolerance: screening for impaired glucose tolerance study 2

BACKGROUND

With positive results from diabetes prevention studies, there is interest in convenient ways to incorporate screening for glucose intolerance into routine care and to limit the need for fasting diagnostic tests.

OBJECTIVE

The aim of this study is to determine whether random plasma glucose (RPG) could be used to screen for glucose intolerance.

DESIGN

This is a cross-sectional study.

PARTICIPANTS

The participants of this study include a voluntary sample of 990 adults not known to have diabetes.

MEASUREMENTS

RPG was measured, and each subject had a 75-g oral glucose tolerance test several weeks later. Glucose intolerance targets included diabetes, impaired glucose tolerance (IGT), and impaired fasting glucose(110) (IFG(110); fasting glucose, 110-125 mg/dl, and 2 h glucose < 140 mg/dl). Screening performance was measured by area under receiver operating characteristic curves (AROC).

RESULTS

Mean age was 48 years, and body mass index (BMI) was 30.4 kg/m(2); 66% were women, and 52% were black; 5.1% had previously unrecognized diabetes, and 24.0% had any "high-risk" glucose intolerance (diabetes or IGT or IFG(110)). The AROC was 0.80 (95% CI 0.74-0.86) for RPG to identify diabetes and 0.72 (0.68-0.75) to identify any glucose intolerance, both highly significant (p < 0.001). Screening performance was generally consistent at different times of the day, regardless of meal status, and across a range of risk factors such as age, BMI, high density lipoprotein cholesterol, triglycerides, and blood pressure.

CONCLUSIONS

RPG values should be considered by health care providers to be an opportunistic initial screening test and used to prompt further evaluation of patients at risk of glucose intolerance. Such "serendipitous screening" could help to identify unrecognized diabetes and prediabetes.

The burden of chronic kidney disease in Australian patients with type 2 diabetes (the NEFRON study)

OBJECTIVE

To estimate the frequency of chronic kidney disease (CKD) in a clinic-based sample of patients with type 2 diabetes in the setting of Australian primary care.

DESIGN, SETTING AND PARTICIPANTS

Expressions of interest were invited from all registered general practitioners in Australia: 500 GP investigators were randomly selected from each stratum (state and urban versus rural location), proportional to the census population, and asked to recruit and provide data for 10-15 consecutively presenting adults with type 2 diabetes between April and September 2005.

MAIN OUTCOME MEASURES

Estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m(2) and evidence of kidney damage on urinalysis (eg, microalbuminuria).

RESULTS

348 GP investigators submitted data for 3893 individuals with type 2 diabetes (52% men; median age, 66 years). Almost one in every four patients consulting their GPs had an eGFR < 60 mL/min/1.73 m(2) (23.1%; 95% CI, 21.8%-24.5%). More than one in three had an elevated urinary albumin-creatinine ratio (ACR) (34.6%; 95% CI, 33.3%-35.9%). There was an overlap of 10.4% of patients with both an eGFR < 60 mL/min/1.73 m(2) and an elevated urinary ACR, meaning that almost one in two patients with type 2 diabetes consulting their GPs (47.1%; 95% CI, 45.8%-48.4%) had CKD. CKD was significantly more common in women, in older people, and in individuals with established macrovascular disease.

CONCLUSION

CKD is a common complication of type 2 diabetes, found in about half of all patients with type 2 diabetes consulting their GPs. Efforts to increase the recognition of CKD will lead to improved care, and possibly survival, of patients with type 2 diabetes.

Prevalence of diabetes in rural Victoria

AIMS

To compare the prevalence of diabetes in adults in small and medium sized towns in a part of rural Victoria

MATERIALS AND METHODS

Participants were usual residents, aged >or=25 years, from randomly selected households in the crossroads undiagnosed disease study (CUDS: six small rural towns and their regional center in rural Victoria). Response rates to an initial census at the household and attendance at a subsequent biomedical examination involved were 70% and 61% (1454), respectively. All non-diabetic participants had an oral glucose tolerance test.

RESULTS

Prevalence of diabetes, IGT, IFG were 7.3 (5.5-9.5)%, 6.9 (5.1-9.9)% and 3.2 (2.0-4.7)% respectively in the regional center and 8.9 (6.9-11.1)%, 4.9 (3.5-6.7)%, 3.0 (1.9-4.5)% in the Shire Capitals. Overall, 31/118 (26.3%) of those with diabetes were previously undiagnosed. Most (83.9%) of those with undiagnosed diabetes remembered having been screened for diabetes in the previous 2 years. Overall screening rates for diabetes were higher than across Victoria as a whole.

CONCLUSIONS

The prevalence of diabetes has probably doubled over the last 15 years in this area. Undiagnosed diabetes is less common than expected, possibly as a result of a more vigorous approach to screening in general practice and in spite of the lower numbers of GPs in the area.

Protease inhibitor-induced diabetic complications : incidence, management and prevention

Protease inhibitors (PIs) have become a crucial element in the treatment of patients infected with HIV. However, the widespread use of PI therapy has also been associated with a number of metabolic adverse effects, including fat redistribution and hyperglycaemia. The objective of this review is a discussion of the incidence, pathophysiology, management and prevention of PI-associated hyperglycaemia. Initial case reports have been followed by large cross-sectional and cohort studies, which demonstrate that the incidence of PI-induced impaired glucose tolerance, as well as frank diabetes mellitus, is significant and demands attention. Investigations into the pathophysiology behind PI-associated hyperglycaemia have identified an underlying problem of insulin resistance that is presumably caused by both direct PI-induced mechanisms and lipotoxicity. Given this, clinical trials have explored the use of various classes of oral hypoglycaemic agents in the management of PI-induced diabetic complications, and the use of insulin therapy must be considered as well. Newer PI agents are also under development, with the hope of reducing metabolic adverse effects. In the meantime, prevention, in the form of dietary modification, regular physical activity and periodic screening for impaired glucose tolerance, must receive heightened attention in the care plan of patients receiving long-term PI therapy.

Prevalence of macrovascular disease amongst type 2 diabetic patients detected by targeted screening and patients newly diagnosed in general practice: the Hoorn Screening Study

OBJECTIVES

Screening for type 2 diabetes has been recommended and targeted screening might be an efficient way to screen. The aim was to investigate whether diabetic patients identified by a targeted screening procedure differ from newly diagnosed diabetic patients in general practice with regard to the prevalence of macrovascular complications.

DESIGN

Cross-sectional population-based study.

SETTING

Population study, primary care.

SUBJECTS

Diabetic patients identified by a population-based targeted screening procedure (SDM patients), consisting of a screening questionnaire and a fasting capillary glucose measurement followed by diagnostic testing, were compared with newly diagnosed diabetic patients in general practice (GPDM patients). Ischaemic heart disease and prior myocardial infarction were assessed by ECG recording. Peripheral arterial disease was assessed by the ankle-arm index. Intima-media thickness of the right common carotid artery was measured with ultrasound.

RESULTS

A total of 195 SDM patients and 60 GPDM patients participated in the medical examination. The prevalence of MI was 13.3% (95% CI 9.3-18.8%) and 3.4% (1.0-11.7%) in SDM patients and GPDM patients respectively. The prevalence of ischaemic heart disease was 39.5% (95% CI 32.9-46.5%) in SDM patients and 24.1% (15.0-36.5%) in GPDM patients. The prevalence of peripheral arterial disease was similar in both groups: 10.6% (95% CI 6.9-15.9%) and 10.2% (4.7-20.5%) respectively. Mean intima-media thickness was 0.85 mm (+/-0.17) in SDM patients and 0.90 mm (+/-0.20) in GPDM patients. The difference in intima-media thickness was not statistically significant.

CONCLUSIONS

Targeted screening identified patients with a prevalence of macrovascular complications similar to that of patients detected in general practice, but with a lower degree of hyperglycaemia.

Irish diabetes detection programme in general practice

OBJECTIVES

To assess the prevalence of undiagnosed diabetes, impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) in patients over the age of 40 years attending their general practitioner (GP) in Ireland, through opportunistic screening, using a three-step screening tool involving self-determined high-risk groups, random venous plasma glucose (RVPG) measurement and oral glucose tolerance tests.

DESIGN

In participating general practices, 100 consecutive patients > 40 years, completed a screening questionnaire relating to diabetes-related symptoms and risk factors. Patients with previously diagnosed diabetes were not excluded from the study and the screening instrument included a question about known diabetes. Patients without known diabetes mellitus (DM) and with at least two risk factors and/or symptoms underwent a RVPG test. Those with an RVPG above 5.5 mmol/l underwent an oral glucose tolerance test.

RESULTS

Forty-one practices returned 3821 questionnaires. The prevalence of Type 2 diabetes mellitus in the study population was 9.2% (353), of whom 23.5% (83) were previously undiagnosed. DM was detected on the basis of an RVPG >11.1 mmol/l in 0.8% (32) of the studied population. DM was detected on the basis of the oral glucose tolerance test in 1.3% (51) of the population. One per cent (39) had a fasting plasma glucose (FPG) > or = 7.0 mmol/l, 0.6% (24) had a 2-h >11.0 mmol/l and 0.3% (12) had both. Diabetes would not have been detected in 12 people had the 2-h test been omitted. The prevalence rate for IFG and/or IGT was 3.9% (148). Of the 103 patients with IGT, 83 (81%) would have been missed had the GTT been omitted.

CONCLUSION

Opportunistic diabetes screening in general practice using a screening questionnaire followed by RVPG testing and GTT for those above 5.5 mmol/l is feasible, with a high participation rate. The use of GTTs rather than fasting glucose testing alone improves patient identification, in particular those with IGT who are at higher cardiovascular risk.

Diabetes detection in Australian general practice: a comparison of diagnostic criteria

OBJECTIVES

To study the influence of different diagnostic criteria on the prevalence of diabetes mellitus and characteristics of those diagnosed.

DESIGN AND SETTING

Retrospective analysis of data from the general-practice-based Australian Diabetes Screening Study (January 1994 to June 1995).

PARTICIPANTS

5911 people with no previous diagnosis of diabetes, two or more symptoms or risk factors for diabetes, a random venous plasma glucose (PG) level > 5.5 mmol/L and a subsequent oral glucose tolerance test (OGTT) result.

MAIN OUTCOME MEASURE

Prevalence of undiagnosed diabetes based on each of three sets of criteria: 1997 criteria of the American Diabetes Association (ADA), 1996 two-step screening strategy of the Australian Diabetes Society (ADS) (modified according to ADA recommendations about lowered diagnostic fasting PG level), and 1999 definition of the World Health Organization (WHO).

RESULTS

Prevalence estimates for undiagnosed diabetes using the American (ADA), Australian (ADS) and WHO criteria (95% CI) were 9.4% (8.7%-10.1%), 16.0% (15.3%-16.7%) and 18.1% (17.1%-19.1%), respectively. People diagnosed with diabetes by fasting PG level (common to all sets of criteria) were more likely to be male and younger than those diagnosed only by 2 h glucose challenge PG level (Australian and WHO criteria only). The Australian (ADS) stepwise screening strategy detected 88% of those who met the WHO criteria for diabetes, including about three-quarters of those with isolated post-challenge hyperglycaemia.

CONCLUSION

The WHO criteria (which include an OGTT result) are preferable to the American (ADA) criteria (which rely totally on fasting PG level), as the latter underestimated the prevalence of undiagnosed diabetes by almost a half. The Australian (ADS) strategy identified most of those diagnosed with diabetes by WHO criteria.

Relative risk of conversion from normoglycaemia to impaired glucose tolerance or non-insulin dependent diabetes mellitus in polycystic ovarian syndrome

BACKGROUND

Cross-sectional studies have shown a high frequency of impaired glucose tolerance (IGT) and non-insulin dependent diabetes mellitus (NIDDM) in women with polycystic ovarian syndrome (PCOS). However, little is known about the change in glucose tolerance that occurs over a period of several years in women with PCOS.

METHODS

Sixty-seven women with PCOS received a 75 g glucose tolerance test and measurement of lipids at baseline and at follow-up after an average time of 6.2 years. All women followed prospectively had normal glucose tolerance (n = 54) or IGT (n = 13) at the start of the study.

RESULTS

Change in glycaemic control from baseline was frequent, with 5/54 (9%) of normoglycaemic women at baseline developing IGT and a further 4/54 (8%) moving directly from normoglycaemic to NIDDM. For women with IGT at baseline, 7/13 (54%) had NIDDM at follow-up. Body mass index (BMI) at baseline was an independent significant predictor of adverse change in glycaemic control.

CONCLUSIONS

Women with PCOS, particularly those with a high BMI, should be reviewed regularly with respect to IGT or NIDDM, as the frequency of impaired glycaemic control is high, and that the rate of conversion from normal glucose tolerance to IGT or NIDDM, or from IGT to NIDDM is substantial.

Diabetes Screening in Canada (DIASCAN) Study: prevalence of undiagnosed diabetes and glucose intolerance in family physician offices

OBJECTIVE

To assess the prevalence of undiagnosed diabetes and glucose intolerance in individuals > or =40 years of age who contacted their family physician for routine care.

RESEARCH DESIGN AND METHODS

The study used a stratified randomized selection of family physicians across Canada that was proportional to provincial and urban/rural populations based on Statistics Canada Census data (1996). Consecutive patients > or =40 years of age were screened for diabetes. If a casual fingerprick blood glucose was >5.5 mmol/l, the patient returned for a fasting venous blood glucose test. If the fasting blood glucose was 6.1-6.9 mmol/l, a 2-h 75-g post-glucose load venous blood glucose was obtained. Results of these tests were used to classify patients in diagnostic categories.

RESULTS

Data were available for 9,042 patients. Previously undiagnosed diabetes was discovered in 2.2% of the patients, and new glucose intolerance was found in an additional 3.5% of patients. Overall, 16.4% of patients had previously known diabetes. The decrease in fasting plasma glucose criterion from 7.8 to 7.0 mmol/l resulted in a 2.2% versus a 1.6% prevalence of new diabetes. Several risk factors were reported in a significantly greater proportion of patients with new glucose intolerance and either new and known diabetes compared with the normal glucose tolerance group of patients.

CONCLUSIONS

Routine screening for diabetes by family physicians is justified in patients > or =40 years of age, given the finding of previously undiagnosed diabetes in 2.2% of these patients and newly diagnosed glucose intolerance in an additional 3.5% of these patients. Another 16.4% of primary care patients > or =40 years of age have known diabetes. This has important implications regarding health resources and physician education.

Selective versus universal screening for gestational diabetes mellitus: an evaluation of predictive risk factors

OBJECTIVE

To assess whether selective screening for gestational diabetes mellitus (GDM) on the basis of risk-factor assessment is a practicable alternative to universal screening.

DESIGN

Case-control study.

SETTING

A 212-bed regional specialist hospital in Melbourne, providing services in obstetrics and gynaecology, paediatrics, geriatrics and rehabilitation.

SUBJECTS

6,032 women who gave birth at the hospital, May 1996 to August 1997 and November 1997 to August 1998; all were screened for GDM, and 313 were diagnosed with the condition.

MAIN OUTCOME MEASURES

Odds ratios (ORs) for risk factors (age, obesity, family history of diabetes mellitus and high-risk racial heritage) in women with GDM compared to those without GDM; proportion of women with GDM whose diagnosis would have been missed by selective screening.

RESULTS

ORs were 1.9 for age > or = 25 years (95% CI, 1.3-2.7), 2.3 for body mass index > or = 27kg/m2 (95% CI, 1.6-3.3), 2.5 for high-risk racial heritage (95% CI, 2.0-3.2), and 7.1 for family history of diabetes mellitus (95% CI, 5.6-8.9). Other proposed criteria (previous GDM and glycosuria) added no further diagnostic power. Selective screening using the above four criteria would have missed two of 313 cases (0.6%) and could have saved screening up to 1,025 women without GDM (17% of all women).

CONCLUSIONS

Selective screening for GDM based on prior risk assessment can reduce the need for testing, with negligible loss of diagnostic efficiency.

Random capillary plasma glucose measurement in the screening of diabetes mellitus in high-risk subjects in Thailand

To assess the usefulness of random capillary plasma glucose (RCPG) measurement in screening for diabetes mellitus in high-risk subjects, a RCPG measurement and a 75-g oral glucose tolerance test (OGTT) were performed in 684 women and 164 men, aged 16-76 years (mean+/-SD: 41.9+/-11.3 years). Risk factors included family history of diabetes in first degree relatives (53.8%), obesity (BMI > or =27 kg/m(2)) in 37.9%, dyslipidemia (78.4%), hypertension, i.e. BP > or =140/90 mmHg (28.5%), and history of gestational diabetes mellitus (16.6%). According to the 1997 ADA/1998 WHO Consultation criteria for a full OGTT, 118 cases (13.9%) were found to have diabetes. Each of 19 cases with RCPG > or =13.3 mmol/l had diabetes according to OGTT, 4.7% of 427 cases with RCPG<6.1 mmol/l had diabetes. Among 402 subjects with RCPG between 6.1 and <13.3 mmol/l, 19.7% were found to have diabetes. Thus, 446 (52.6%) of 848 subjects would have been saved from OGTT if RCPG was used as a screening test, in comparison to 33.1% if the cutpoints for RCPG (12.2 and 5.5 mmol/l) recommended by WHO Study Group (1985)/WHO Consultation (1998) were applied. Therefore, RCPG measurement is a useful screening test for the screening of diabetes mellitus in high-risk subjects.

Diabetes risk score: towards earlier detection of type 2 diabetes in general practice

BACKGROUND

Type 2 diabetes is common, costly and often goes unrecognised for many years. When patients are diagnosed, the majority exhibit associated tissue damage or established cardiovascular risk. Evidence is accumulating that earlier detection and management of diabetes and related metabolic abnormalities may be beneficial. We aimed to develop and evaluate a score based on routinely collected information to identify people at risk of having undetected diabetes.

METHODS

A population-based sample of 1077 people, aged 40 to 64 years, without known diabetes, from a single Cambridgeshire general practice, underwent clinical assessment including an oral glucose tolerance test. In a separate 12-month study, 41 practices in southern England reported clinical details of patients aged 40 to 64 years with newly diagnosed Type 2 diabetes. A notional population was created by random selection and pooling of half of each dataset. Data were entered into a regression model to produce a formula predicting the risk of diabetes. The performance of this risk score in detecting diabetes was tested in an independent, randomly selected, population-based sample.

RESULTS

Age, gender, body mass index, steroid and antihypertensive medication, family and smoking history contributed to the score. In the test population at 72% specificity, the sensitivity of the score was 77% and likelihood ratio 2.76. The area under the receiver-operating characteristic curve was 80%.

CONCLUSIONS

A simple score, using only data that are routinely collected in general practice, can help identify those at risk of diabetes. This score could contribute to efficient earlier detection through case-finding or targeted screening.

Predicting the occurrence of diabetes mellitus in recipients of heart transplants

AIMS

To establish the incidence of post-transplant diabetes mellitus (PTDM) and factors predictive of its development.

METHODS

This was a retrospective review (using hospital records and transplant database) of 97 consecutive adult patients who underwent cardiac transplantation at St Vincent's Hospital, Sydney, Australia.

RESULTS

Mean follow-up was 27 months. Excluding five patients who had pre-existing diabetes, the cumulative incidence of PTDM was 15.7%. Pre-transplant random blood glucose (5.6 +/- 0.8 vs. 5.2 +/- 0.6 mmol/l, P<0.05), family history (46% vs. 15%, P<0.05) and a continuing requirement for insulin on the second post-transplant day (54% vs. 15%, P< 0.01) differed in those who developed PTDM as opposed to those who remained free of diabetes. Patients who developed PTDM had received slightly higher mean doses of prednisolone at three months (0.21 +/- 0.03 vs. 0.19 +/- 0.03 mg. kg(-1)/day(-1), P<0.01). Of the factors identifiable prior to initial hospital discharge, only family history of diabetes mellitus and second post-transplant day insulin requirement independently predicted the occurrence of PTDM.

CONCLUSIONS

A family history of diabetes and the need for insulin beyond the first 24 h after transplantation are factors identifiable prior to hospital discharge, which predict patients at risk of developing PTDM. In such patients, consideration to minimizing the dose of glucocorticoids should be given where possible.

Diagnosis, prediction, and natural course of HIV-1 protease-inhibitor-associated lipodystrophy, hyperlipidaemia, and diabetes mellitus: a cohort study

BACKGROUND

The prevalence and severity of lipodystrophy syndrome with long-term therapy for HIV-1 infection that includes a protease inhibitor is unknown. We studied the natural course of the syndrome to develop diagnostic criteria and identifying markers that predict its severity.

METHODS

We assessed 113 patients who were receiving HIV-1 protease inhibitors (mean 21 months) and 45 HIV-1-infected patients (28 with follow-up) never treated with a protease inhibitor. Lipodystrophy was assessed by questionnaire (including patients' rating of severity), physical examination, and dual-energy x-ray absorptiometry. Body composition and fasting lipid and glycaemic variables were compared with data obtained 8 months previously. Oral glucose tolerance was investigated.

FINDINGS

There was 98% concordance between patients' reports of the presence or absence of lipodystrophy (reported by 83% of protease-inhibitor recipients and 4% of treatment-naïve patients; p=0.0001) and physical examination. Patients' ratings of lipodystrophy were significantly associated with declining total body fat (p=0.02). Lower body fat was independently associated with longer duration of protease-inhibitor therapy and lower bodyweight before therapy, and more severe lipodystrophy was associated with higher previous (p < 0.03) and current (p < or = 0.01) triglyceride and C-peptide concentrations, and less peripheral and greater central fat (p=0.005 and 0.09, respectively). Body fat declined a mean 1.2 kg over 8 months in protease-inhibitor recipients (p=0.05). The prevalence of hyperlipidaemia remained stable over time (74% of treated patients vs 28% of naïve patients; p=0.0001). Impaired glucose tolerance occurred in 16% of protease-inhibitor recipients and diabetes mellitus in 7%; in all but three patients these abnormalities were detected on 2 h post-glucose load values.

INTERPRETATION

Diagnosis and rating severity of lipodystrophy is aided by the combination of physical examination, patient's rating, and measurement of body fat, fasting triglycerides, and C-peptide. Weight before therapy, fasting triglyceride, and C-peptide concentrations early in therapy, and therapy duration seem to predict lipodystrophy severity. Lipodystrophy was common and progressive after almost 2 years of protease inhibitor therapy, but was not usually severe. Hyperlipidaemia and impaired glucose tolerance were also common.